HomeMy WebLinkAboutSeptic Pumping Slip - 9/4/2024 - Septic Pumping Slip - 183 FOREST STREET 9/4/2024 . Commonwealth of Massachusetts ssachusett5 C,
City/Town of Andover
System Dumping Record ��
Form 4 2025
DEP has provided this form for use by local Boards of Health. Oth a be used, but the
information must be substantially the same as that provided here, e check with your
local Board of Health to determine the form they use.The System Pumping Recor fitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:when
filling out forms 1. System Location:
on the computer, .
use only the tab �....__.
key to move your Ad ress
cursor-do not r 4 b v 1,
use the return --. ... ...._. __ _---..... ..... __ _.. _ .-- ------_-- . .
key. City own State Zip Code
� Qwner 2. System :.
_. .----------- .........
Nam 11 e
Address(if different from location)
City/Town S#a#e Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. quantity Pumped: G
IJake ,_,, allons
3. Component: ElCesspool(s) E5 Septic Tank ® Tight Tank ❑ Grease Trap
❑ Other(describe): -----------
4. Effluent Tee Filter presents ❑ Yes No If yes, was it cleaned? Q Yes ❑ No
5. Observed cgndition of component pumped:
y tem Pumped By:6. utivl "� I ( _
__... ._. ......
Name Vehicle License Number
Company
7. Location wher ntents were disposed:
....._ _ _ ..-._..._. ---... _ - — _. __
Signatb e of H uler Date
Signature of R wing Facrtsty"(or attach facility receipt) Date
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